Pharmacoeconomic considerations in anaesthetic use

Healthcare costs are rising in all areas of medicine, especially in high technology specialities such as anaesthesia. Therefore, cost containment and reduction have become major goals in many hospitals and anaesthesia departments. One area that has received substantial attention is the cost of pharmaceutical products, in particular the cost of newer, shorter-acting inhaled and intravenous anaesthetics, analgesics and neuromuscular blocking agents. Numerous pharmacoeconomic studies have been published on the theoretical analysis of anaesthetic drug costs and the potential benefit of various anaesthesia techniques. However, the results are not conclusive and anaesthesia departments continue to seek ways to reduce costs. In this review, we intend to discuss cost terminology, common areas of cost containment in anaesthesia and the relationship of anaesthesia care costs to total perioperative costs.     

Pharmacoeconomic considerations in anaesthetic use

Healthcare costs are rising in all areas of medicine, especially in high technology specialities such as anaesthesia. Therefore, cost containment and reduction have become major goals in many hospitals and anaesthesia departments. One area that has received substantial attention is the cost of pharmaceutical products, in particular the cost of newer, shorter-acting inhaled and intravenous anaesthetics, analgesics and neuromuscular blocking agents. Numerous pharmacoeconomic studies have been published on the theoretical analysis of anaesthetic drug costs and the potential benefit of various anaesthesia techniques. However, the results are not conclusive and anaesthesia departments continue to seek ways to reduce costs. In this review, we intend to discuss cost terminology, common areas of cost containment in anaesthesia and the relationship of anaesthesia care costs to total perioperative costs.     

Implementation of statin prescribing guidelines: a cost effectiveness analysis

□ The evidence that statins reduce coronary heart disease mortality and morbidity is strong yet these drugs are under‐utilised in the UK □ Statin prescribing guidelines were implemented in five general medical practices using academic detailing, audit, feedback and written materials □ Statin prescribing increased following introduction of the guidelines, to a greater extent than predicted by regression analysis in the absence of intervention, with an additional 102 patients being treated 12 months after intervention □ Assuming benefits in this patient group are equivalent to those seen in the major trials, this equates to an additional 3.6 major coronary events and 1.5 coronary deaths prevented □ Including both the cost of guideline introduction and the additional statin drug costs, the cost per event prevented was 28,063 for major coronary events and £67,351 for coronary deaths.     

The determinants of hospital cost: a cost–volume–profit analysis of health services in the Occupied Territories: Palestine

Objective The purpose of this study is to examine the unit costs of a multi‐service hospital in Palestine for the period 2005–2007. We investigate the cost structure of the Rafidya Hospital located in Nablus city, for both inpatient and outpatient departments. Methods This study uses cost–volume–profit (CVP) analysis, also known as breakeven analysis. CVP analysis requires examining total costs, along with fixed and variable costs. CVP analysis illuminates how changes in assumptions about cost behaviour and the relevant range in which those assumptions are valid affect the relationships among revenues, variable costs and fixed costs at various production levels. Key findings For the hospital of interest, we find that fixed costs account for 70% of total costs, and variable costs were 30% of total costs. Inpatient departments accounted for 86% of total costs, and outpatient departments were 14% of total costs. Results of the breakeven analysis illustrate that several departments charge sufficient fees to cover all unit costs. Conclusions Results provide useful information about unit cost based on four categories: (1) unit cost per admission of each department, (2) unit cost per patient day of each department, (3) unit cost per admission with annual capital cost of each department and (4) unit cost per patient day with annual capital cost. Our results provide hospital cost information that can be used by decision‐makers to provide and expand healthcare services, in an effort to increase sustainability and profitability. The use of cost analysis by administrators and regulators will improve the quality of financial information, as well as enhance the efficient use of scarce resources.     

Variation in the management of PONV and pain in day case surgery: implications for evidence based practice

□ This study aimed to provide information on the variation in perioperative anaesthetic care for principal types of day case adult and paediatric procedures including the use of intraoperative analgesia and the treatment of post‐operative nausea and vomiting □ A structured postal survey comprising closed questions was sent to consultant anaesthetists involved in anaesthetising patients for day case surgery in United Kingdom National Health Service trusts □ This survey found wide variation in the selection of intraoperative analgesics and treatment anti‐emetics for the potential management of patients having three common day surgery procedures □ It is likely that the wide variation in practice seen in this, and previous studies, is due to uncertainty about effectiveness □ The lack of consensus about the preferred choice of analgesia and anti‐emetics provides a challenge to pharmacists and clinicians in the development of evidence based guidelines.     

Low-flow anaesthesia. Does it have potential pharmacoeconomic consequences?

Healthcare reform has placed increasing pressure on anaesthetists to consider the costs of current anaesthesia strategies. Although the cost of anaesthesia constitutes only a small proportion of total healthcare costs, anaesthetic drug expenditures have been a focus of cost-containment efforts. Low-flow anaesthesia is a simple method of reducing the fresh gas flow rate for anaesthetic gases during inhalational anaesthesia. A knowledge of the pharmacokinetic behaviour of inhaled anaesthetics and the use of modern equipment and monitoring technology meet the requirements for safe application of this anaesthetic technique. Millions of patients receive general anaesthesia each year, and thus the use of this technique could generate substantial savings in anaesthetic drug expenditure without reducing the patient's comfort or increasing adverse events. The new inhaled anaesthetics desflurane and sevoflurane, which have low tissue solubility, provide promising options when used in low-flow anaesthesia. Apart from the economic advantages, low-flow anaesthesia helps to reduce environmental pollution and is associated with several physiological benefits for the patient. Low-flow anaesthesia is a simple but highly effective method of cost minimisation that can be applied to a large number of patients without any compromise in patient care or safety.     

Assessing the total costs of blood delivery to hospital oncology and haematology patients

ABSTRACT

Objective: To determine direct costs associated with a blood transfusion session in two hospital settings.

Research design and methods: The study was conducted in two United Kingdom hospital sites during April 2004. Transfusion sessions for patients receiving units of red blood cells within either haematology or oncology departments were followed using time and motion techniques to measure the direct costs. Other data were collected from the centres to calculate the cost of disposables, blood wastage and blood bank machines.

Results: Total mean staff cost per transfusion of 2?units was £37.24 (£9.68 for blood bank and £27.56 for ward procedures). The mean cost of disposables was £13.25 and the mean cost for blood products was £287.56. The mean cost of wastage was £11.86 per transfusion. After including other derived costs, such as hospital stay, the mean cost for a transfusion of 2?units of blood was estimated to be £546.12.

Conclusion: This study estimates the cost of an average blood transfusion of 2?units to be £546.12. It should be noted that significant indirect costs, such as those incurred by patients, their carers and societal costs, have not been considered. Against the background of finite blood resources and other factors such as patient quality of life, blood transfusion may not represent the best choice for patient care. Alternative treatments should be considered.     

An economic evaluation of sevelamer in patients new to dialysis

ABSTRACT

Objective: The overall objective of this study was to estimate the costs and outcomes associated with treatment with sevelamer for hyperphosphataemia compared with calcium-based binders.

Methods: Using published data on mortality and hospitalisation rates, a Markov model was developed to predict health outcomes and associated costs for the treatment of hyperphosphataemia using either sevelamer or calcium binders in chronic kidney disease patients who had recently started haemodialysis. Patient outcomes were modelled for 5 years, and incremental cost-effective ratios (ICERs) were calculated for sevelamer relative to calcium carbonate and calcium acetate binders. The perspective adopted was that of the UK National Health Service.

Results: The total 5-year discounted treatment cost for patients treated with sevelamer is £24?216, while for the calcium carbonate group total cost was £17?695. This is an incremental cost of £6521 per sevelamer-treated patient over 5 years. Patients receiving sevelamer can be expected to experience 2.70 quality-adjusted life years (QALYs) compared to 2.46 for those treated with calcium carbonate (i.e. an incremental gain of 0.24 QALYs). This results in an incremental cost per QALY of £27?120 and an incremental cost per life year gained of £15?508. Results were similar with calcium acetate.

Conclusion: Together with the unique morbidity and mortality benefits, this study suggests that treatment with sevelamer confers clinical benefits with a modest investment of additional economic resources.     

Economic evaluation of etoricoxib versus non-selective NSAIDs in the treatment of ankylosing spondylitis in the UK

ABSTRACT

Objectives: To evaluate the cost-effectiveness of etoricoxib, a cyclooxygenase (COX)‐2 selective inhibitor, versus non-selective nonsteroidal anti-inflammatory drugs (nsNSAIDs) in the treatment of ankylosing spondylitis (AS).

Methods: The cost-effectiveness of etoricoxib versus nsNSAIDs was evaluated from the UK National Health Service (NHS) and society perspective with a decision-analytic model. Patients stayed on initial therapy throughout 52 weeks unless they experienced an adverse event (AE) or lacked efficacy, in which case they switched to another nsNSAID or a tumor necrosis factor alpha antagonist. Efficacy data were obtained from a 1‐year etoricoxib clinical trial in AS. Bath AS Functional Index (BASFI) data were translated into Quality Adjusted Life Year (QALY) weights using a published data on the relation between BASFI and Short-form (SF) 36 Quality of life scores, as well as the relation between SF‐36 and utility. Safety data were based on meta-analyses of etoricoxib trials. Information on treatment pathways, resource consumption, and absenteeism from work was obtained from literature and experts. Model outcomes included QALYs, perforations, ulcers, or bleeds, cardiovascular events, and costs.

Results: Etoricoxib was cost-effective compared to nsNSAIDs in terms of cost per QALY saved (£5611). Probabilistic sensitivity analysis found a 77% probability of the incremental cost per QALY saved being within a threshold for cost-effectiveness of £20?000. The expected direct costs over the 52-week period were £1.23 (95% uncertainty distribution £1.10; £1.39) and £1.13 per day (£0.78; £1.55) for patients starting with etoricoxib and nsNSAIDs, respectively. When costs related to absenteeism were taken into account, the cost per QALY saved was £281.

Conclusions: Given the underlying assumptions and data used, this economic evaluation demonstrated that, compared to nsNSAIDs, etoricoxib is a cost-effective therapy for AS patients in the UK.     

A model of the long-term cost effectiveness of scheduled maintenance treatment with infliximab for moderate-to-severe ulcerative colitis

Background Infliximab (IFX) has been shown to be efficacious in moderate‐severe ulcerative colitis (UC). Aim To evaluate the cost‐effectiveness of a scheduled maintenance treatment (SMT) with IFX in moderate‐severe UC patients. Methods A Markov model was constructed to simulate the progression of a cohort of moderate‐severe UC patients treated with IFX (5 mg/kg) SMT. Transitions were estimated from two phase III trials of IFX (ACT I and ACT II). Standard care, comprising immunomodulators and/or corticosteroids was used as a comparator. Two separate treatment strategies were evaluated – continued treatment in IFX responders and continued treatment in IFX patients achieving remission. The dose of IFX was estimated for a 73 kg typical UC patient in the UK. The results were calculated over 10 years using a discount rate of 3.5% for costs and outcomes. The outcome measure was quality‐adjusted life years (QALYs) estimated using EQ‐5D. Sensitivity analyses explored the uncertainty around the results. Results The incremental cost effectiveness ratio (ICER) for IFX was £27 424 in the responder strategy and £19 696 in the remission strategy at 10 years. In sensitivity analysis, the ICER for IFX in the responder strategy ranged from £21 066 to £86 322 and in the remission strategy ranged from £14 728 to £46 765. The model time horizon and patient body weight were important factors affecting results. Conclusion Eight‐week SMT with IFX appears to be a cost‐effective treatment option for adult patients suffering from moderate to severe UC.     

Induction of anaesthesia: a guide to drug choice

In developed countries, the choice of an anaesthetic agent for induction of anaesthesia remains based mainly on its pharmacodynamic properties. Until now, cardiovascular effects were the main factor in this decision. However, other factors, such as the depth of anaesthesia and effects on cortisol synthesis, can modify this simplistic view. A better understanding of the relationships between the pharmacokinetics and pharmacodynamics of these drugs, and the availability of new techniques, such as target-controlled infusions of anaesthetic drugs and inhalation induction, have led practitioners to the understanding that the way a drug is administered is a far more important factor for maintaining haemodynamic stability than the specific agent used. The ability of a drug to maintain spontaneous ventilation and to relax the upper airway is another factor in this decision, especially when considering difficult intubation, laryngeal mask insertion or tracheal intubation without neuromuscular blockade. Beyond the factors mentioned above, anaesthetists adapt current practice to suit patients' willingness to comply with anaesthesia and to avoid the adverse effects that are most often feared by the patient. Although most practitioners are not concerned with the cost of anaesthesia, cost-containment policies have led some institutions to restrict the use of the more expensive drugs to particular indications. However, this is too simplistic an approach for the reduction of global costs, as other direct medical costs, such as those for staffing, form a greater proportion of total costs than do direct drug costs. Cost-benefit and cost-efficacy studies of the anaesthetics used for induction of anaesthesia are needed to help anaesthetists to choose a drug based on both cost and pharmacodynamic or pharmacokinetic properties.     

The use of sublingual glyceryl trinitrate and aspirin in angina patients and enhancement of coronary heart disease databases

□ Audit involving 95 per cent of community pharmacists in one LHCC □ Data were gathered using a semi‐structured questionnaire □ A list of all participating patients was sent to each GP surgery in the locality to enhance their CHD database □ Not all appropriate angina patients are receiving aspirin □ Patients' knowledge of GTN management was poor and should be improved upon by input from healthcare professionals     

Modelling the economic and health consequences of cardiac resynchronization therapy in the UK

ABSTRACT

Objective: Clinical evidence supports the use of cardiac resynchronization therapy (CRT) in advanced heart failure, but its cost-effectiveness is still unclear. This analysis assessed the economic and health consequences in the UK of implanting a CRT in patients with NYHA class III-IV heart failure.

Methods: A discrete event simulation of heart failure was used to compare the course over 5 years of 1000 identical pairs of patients – one receiving both CRT and optimum pharmacologic treatment (OPT), the other OPT alone. All inputs were obtained from the data collected in the CArdiac REsynchronization in Heart Failure (CARE-HF) trial and a hospital in the UK. Direct medical costs (in 2004 £) from the perspective of the National Health Service were considered. Both costs and benefits were discounted at 3.5%. Sensitivity analyses addressed all model inputs and multivariate analyses were performed by varying key parameters simultaneously.

Results: The model predicted 471 deaths and 2263 hospitalizations over 5 years with OPT alone and 348 deaths and 1764 hospitalizations with CRT, equivalent to a 26% reduction in mortality and 22% in hospitalizations, at a discounted cost of £11?423 per patient with CRT vs. £4900 with OPT alone. CRT was predicted to increase quality-adjusted survival by 0.43 QALYs per patient, resulting in an incremental cost-effectiveness ratio of £15?247 per QALY gained (range: £12?531–£23?184). Sensitivity analyses revealed that this outcome was most sensitive to time horizon and cost of implantation.

Conclusion: Based on these 5‐year analyses, CRT is expected to yield substantial health benefits at a reasonable cost.     

Cost effectiveness of cilostazol compared with naftidrofuryl and pentoxifylline in the treatment of intermittent claudication in the UK

ABSTRACT

Objective: To estimate the cost effectiveness of cilostazol (Pletal) compared to naftidrofuryl and pentoxifylline (Trental) in the treatment of intermittent claudication in the UK.

Design and setting: This was a modelling study on the management of patients with intermittent claudication who are 40 years of age or above and have at least six months history of symptomatic intermittent claudication, secondary to lower extremity arterial occlusive disease. The study was performed from the perspective of the UK's National Health Service (NHS).

Methods: Clinical outcomes attributable to managing intermittent claudication were obtained from the published literature and resource utilisation estimates were derived from a panel of vascular surgeons. Using decision analytical techniques, a decision model was constructed depicting the management of intermittent claudication with cilostazol, naftidrofuryl and pentoxifylline over 24 weeks in the UK. The model was used to estimate the cost effectiveness (at 2002/2003 prices) of cilostazol relative to the other treatments.

Main outcome measures and results: Starting treatment with cilostazol instead of naftidrofuryl is expected to increase the percentage improvement in maximal walking distance by 32% (from 57% to 75%) for a 12% increase in NHS costs (from £801 to £895). Treatment with cilostazol instead of pentoxifylline is expected to increase the percentage improvement in maximal walking distance by 67% (from 45% to 75%) and reduce NHS costs by 2% (from £917 to £895). Treatment with naftidrofuryl instead of pentoxifylline is expected to increase the percentage improvement in maximal walking distance by 27% (from 45% to 57%) and decrease NHS costs by 14% (from £917 to £801).

Conclusion: Within the limitations of our model, starting treatment with cilostazol is expected to be a clinically more effective strategy for improving maximal walking distance at 24 weeks than starting treatment with naftidrofuryl or pentoxifylline and potentially the most cost effective strategy. Moreover, the acquisition cost of a drug should not be used as an indication of the cost effectiveness of a given method of care.     

Estimating the economic impact of a half-day reduction in length of hospital stay among patients with community-acquired pneumonia in the US

ABSTRACT

Background: A recent study suggested that levofloxacin significantly reduces the hospital length of stay (LOS), by 0.5 days (p?=?0.02), relative to moxifloxacin in patients with community-acquired pneumonia (CAP). The current analysis evaluated the potential economic impact of this half-day reduction in LOS.

Methods: A cost model was developed to estimate the impact of a half-day reduction in LOS for CAP hospitalizations in the US. CAP incidence, hospitalization rate, and costs were obtained from published studies in PubMed and from publicly available government sources. The average daily cost of hospitalization was estimated for fixed costs, which comprise 59% of total inpatient costs. Costs from prior years were inflated to 2007 US dollars using the consumer price index. A range of cost savings, calculated using inpatient CAP costs from several studies, was extrapolated to the US CAP population.

Results: Using the Centers for Disease Control National Hospital Discharge estimate of 5.3 days LOS for CAP, and an average cost (2007 $US) of $13,009 per CAP hospitalization, a daily fixed cost of $1448 was estimated. The resultant half-day reduction in costs associated with LOS was $724/hospitalization (range $457 to $846/hospitalization). When fixed and variable costs were considered, the estimated savings were $1227.27/episode. The incidence of CAP was estimated to be 1.9% (5.7 million cases/year based on current population census), and the estimated rate of CAP hospitalization was 19.6% (1.1 million annual hospitalizations). At $13,009/CAP-related hospitalization, total fixed inpatient costs of $8.6 billion annually were projected. The half-day reduction in LOS would therefore generate potential annual savings of approximately $813 million (range $513 million to $950 million). When total costs (fixed plus variable) were estimated, the mean savings for a half-day reduction would be approximately $1227/episode (range of $775 to $1434) or $1.37 billion annually in the US CAP population (range of $871 million to $1.6 billion). Limitations include the use of a single study for the estimation of fixed costs but a diversity of sources used for estimates of other variables, and lack of data with respect to the effects on costs of diagnostic-related groups, discounted contracts, and capitated payments.

Conclusions: A relatively small decrease in LOS in CAP can have a substantial cost impact, with estimated savings of $457 to $846 per episode or $500-$900 million annually. Additional evaluation is warranted for interpreting these cost-savings in the context of current antibiotic prescribing patterns.